Failure to Protect Residents from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from resident-to-resident sexual abuse, resulting in multiple incidents involving a resident with a known history of sexually inappropriate behavior. This resident, who was a registered sexual offender with severe cognitive impairment and diagnoses including dementia and a history of stroke, was documented to have engaged in inappropriate sexual contact and touching of non-consenting residents. Despite the resident's care plan identifying the risk and outlining interventions such as monitoring whereabouts and providing counseling, there was no evidence that these interventions were consistently implemented or documented. Staff interviews and clinical records revealed that the resident repeatedly wandered into other residents' rooms and engaged in inappropriate behaviors, including touching, kissing, and fondling other residents, some of whom were severely cognitively impaired or physically unable to defend themselves. Multiple staff members and residents reported ongoing incidents of inappropriate sexual behavior by the resident, with some staff expressing frustration that their concerns were dismissed or not acted upon by facility management. Staff accounts indicated that the behavior was widely known throughout the facility, with some staff being told by management that such actions were permissible or not considered inappropriate. There were also reports that management failed to investigate or take action on complaints, and that the resident's behavior had been escalating over several months. Documentation in the clinical records for affected residents did not reflect that concerns were reviewed or addressed by clinicians, and there was a lack of timely updates to care plans or implementation of effective interventions to prevent further incidents. The deficiency resulted in at least five residents being subjected to unwanted sexual contact or harassment, including one incident where a resident with severe cognitive impairment was found in a vulnerable state in an unoccupied room with the offending resident. Observations and interviews confirmed that the resident's actions were non-consensual and caused distress to the victims, some of whom were unable to communicate or defend themselves. The facility's failure to implement and document effective interventions, respond appropriately to staff and resident reports, and protect residents from abuse created an Immediate Jeopardy situation.
Removal Plan
- Resident R1 will remain on 1:1. Facility will ensure 1:1 is in place at all times by scheduling specific staff to perform this 1:1 duty each day on all three shifts.
- Facility will provide 1:1 to Resident R1 to ensure safety of Residents R3, R4, R5, and R6 from resident initiated sexual abuse.
- Resident R1 and R2 will be separated.
- Resident R2 will be assessed for injuries and sent to the hospital for further evaluation.
- Current female residents who are cognitively intact will be interviewed. Current female residents who are cognitively impaired will have a skin assessment completed.
- All staff will be educated on Abuse/Neglect and Reporting of Incident and Accidents by the Director of Nursing or designee.
- Resident R1 will remain on 1:1.
- Resident R1 will be evaluated by psychiatry services in conjunction with the facility medical director.
- Audits will be completed on female residents who are cognitively intact to ensure residents safety. These audits will be completed by Social Services or designee.
- Audits will be completed on female residents who are cognitively impaired to ensure residents safety.
- An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the Administrator.
- Affected residents will be seen by facility contracted psychiatry/psychology provider if they request to do so to address their emotional trauma.
- This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met.